Crisis management during anaesthesia: awareness and anaesthesia.

BACKGROUND: Patient awareness during general anaesthesia has considerable potential for severe emotional distress in the patient as well as professional, personal, and financial consequences for the anaesthetist. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for awareness, in the detection and management of potential awareness in association with general anaesthesia. METHOD: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: Of the first 4000 reports received by AIMS, there were 21 incidents of patient awareness under general anaesthesia, and 20 of patients being paralysed while awake from "syringe swaps" before induction of anaesthesia. In 12 of the 21 reports there was an obvious cause, most commonly a low concentration of volatile agent (8 of 12 reports). The AIMS "core" crisis management algorithm would have detected the cause of awareness in all of these cases. In nine reports the course of anaesthesia appeared unremarkable, and in these the algorithm would not have been expected to detect or prevent awareness. Volatile agent monitoring would have prevented some cases of awareness, as would bispectral index electroencephalographic (BIS) monitoring. The role of BIS monitoring is still contentious, but it should be considered for high risk patients. CONCLUSION: Awareness should be minimised by thorough checking of equipment, particularly vaporisers, and frequent application of a structured scanning routine. Awareness may occur during crisis management and aftermath protocols should include patient follow up to detect and manage awareness when it occurs.

Crisis management during anaesthesia: pneumothorax.

BACKGROUND: Pneumothorax is a potentially dangerous condition which may arise unexpectedly during anaesthesia. The diagnosis is one of exclusion, as initial changes in vital signs (cardiorespiratory decompensation and difficulty with ventilation) are non-specific, and other causes of such changes are more common, whereas local signs may be difficult to elicit, especially without full access to the chest. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for pneumothorax, in the management of pneumothorax occurring in association with anaesthesia. METHODS: Reports of pneumothorax were extracted and studied from the first 4000 incidents reported to the Australian Incident Monitoring Study (AIMS). The potential performance of the structured approach, using the combination of algorithims described above for each of the relevant incidents, was compared with the actual management as reported by the anaesthetists involved. RESULTS: Pneumothorax was noted as a possible diagnosis in 65 reports; 24 cases had a confirmed pneumothorax, of which 17 were in association with general anaesthesia. It was considered that, correctly applied, the application of the algorithms would have led to earlier recognition of the problem and/or better management in 12% of cases. CONCLUSION: Any pneumothorax may become a dangerous tension pneumothorax with the application of positive pressure ventilation. Limited access to the chest during anaesthesia may compromise the diagnosis. Recognition of any preoperative predisposition to a pneumothorax (for example, iatrogenic or traumatic penetrating procedures around the base of the neck) and close communication with the surgeon are important. Aspiration diagnosis in suspected cases and correct insertion of a chest drain are essential for the safe conduct of anaesthesia and surgery.

Crisis management during anaesthesia: anaphylaxis and allergy.

BACKGROUND: Anaphylactic and anaphylactoid reactions during anaesthesia are a major cause for concern for anaesthetists. However, as individual practitioners encounter such events so rarely, the rapidity with which the diagnosis is made and appropriate management instituted varies considerably. OBJECTIVES: To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for anaphylaxis, in the management of severe allergic reactions occurring in association with anaesthesia. METHODS: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual performance as reported by the anaesthetists involved. RESULTS: There were 148 allergic reactions among the first 4000 incidents reported to AIMS. It was considered that, properly applied, the structured approach would have led to a quicker and/or better resolution of the problem in 30% of cases, and would not have caused harm had it been applied in all of them. CONCLUSION: An increased awareness of the diverse clinical manifestations of allergy seen in anaesthetic practice, together with the adoption of a structured approach to management should improve and standardise the treatment and improve follow up of patients suspected of having suffered a significant allergic reaction under anaesthesia.

Crisis management during anaesthesia: recovering from a crisis.

Preventing harm to the patient is the priority during a crisis. After a major incident, and especially when a patient has been harmed, there are a number of matters to be addressed: the ongoing care of the patient; documentation of the incident; investigation of the root causes; completion of reports; interviews with the patient and/or the next of kin, together with apologies and expression of regret; updates and ongoing support for friends and relatives; a word of thanks to the staff involved for their assistance; formal debriefing of staff for quality assurance and possibly ongoing support and a separate debriefing for psychological purposes; ensuring that the recommendations of the root cause analysis are carried out; or, failing that, that the issues are logged on a risk register. The extent and depth of the follow up protocol depends on what, if any, harm may have been done. This may constitute completion of an incident report; notification of an equipment failure to a federal regulatory authority; arranging consultations with a mental health professional to manage psychological sequelae (especially following an awareness episode); follow up during weeks of intensive care treatment; or, when a death has occurred, a full medico-legal and/or coronial set of procedures. A precis is appended in an action card format.

Review of efficiencies and patient satisfaction in Australian and New Zealand day surgery units: a pilot study.

A pilot study was performed in eight Australasian day surgery facilities with a purpose of identifying common trends and differences. A prospective study was designed in which information was collected on 826 patients over a two-week period. Patients were well matched for age, anaesthetic type and mean surgical time. Three facility types were identified and results were statistically corrected for any differences that ASA status, age and surgical time may have made. Patient preoperative waiting time, recovery room times, delayed discharge time and unanticipated admission rates showed favourable outcome trends for free-standing facilities compared with hospital-integrated facilities where day patients had a shared recovery with inpatients. Similar trends were seen with patient opinions of waiting times and recovery periods. In summary, this pilot study has demonstrated the impact of different facility types on efficiencies and patient satisfaction both of which have important cost implications and relevance to those involved in continuous quality improvement processes in day surgery.

Death on the table. Some thoughts on how to handle an anaesthetic-related death.

This describes one way to handle the aftermath of anaesthetic catastrophe. The techniques of how to share bad news, interview relatives, complete official forms, deal with the legal process and debrief colleagues are outlined. It is hoped that this article will promote discussion on this topic and improve communication with all those affected by mishaps in the operating suite.

Medical aspects of the 'Ash Wednesday bushfires'.

In the Dandenong mountains, within 30 kilometres of Melbourne, natural bush and Eucalypt forest hide the homes and narrow roadways of townships which were destroyed in one of the worst series of fires in Victoria's history--the 'Ash Wednesday bushfires' on 16 February 1983. In this article the medical aspects of that holocaust are classified similarly to a counter disaster plan.